What is the recommended treatment for prepatellar bursitis (plumber's knee)?

Treatment of Prepatellar Bursitis (Plumber's Knee)

The recommended first-line treatment for prepatellar bursitis (plumber's knee) is relative rest, ice therapy, NSAIDs, and compression, with more invasive treatments reserved for cases that fail conservative management. 1, 2

Initial Conservative Management

Rest and Activity Modification

• Relative rest should be implemented to prevent ongoing damage by avoiding activities that worsen pain (especially kneeling) while maintaining some activity to prevent muscle atrophy and deconditioning 1
• Complete immobilization should be avoided as tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 1

Ice Therapy (Cryotherapy)

• Apply ice through a wet towel for 10-minute periods to provide short-term pain relief, reduce swelling, and blunt inflammatory response 1
• Cryotherapy is effective by slowing the release of blood and proteins from surrounding vasculature by reducing tissue metabolism 1

Medications

• NSAIDs (oral or topical) are recommended for pain relief and reducing inflammation 2, 3
  • The recommended starting dose of naproxen is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required 3
  • Topical NSAIDs may be preferable due to their eliminated risk of gastrointestinal side effects 1
• Acetaminophen (up to 4,000 mg/day) can be used as an alternative first-line medication for pain relief in patients who cannot take NSAIDs 2

Compression and Support

• Compression bandaging can help reduce swelling and provide support to the affected area 4
• Weight reduction should be considered for overweight patients to reduce pressure on knee joints 2

Second-Line Treatments

Aspiration

• Bursal aspiration may be necessary for significant effusions or diagnostic purposes to rule out septic bursitis 4
• Aspiration should be performed with sterile technique, and the fluid should be sent for cell count, Gram stain, and culture if infection is suspected 4, 5

Corticosteroid Injections

• Intra-bursal corticosteroid injections may be considered for non-septic bursitis that doesn't respond to initial conservative measures 1
• Caution should be exercised as corticosteroids may inhibit healing and reduce tensile strength of tissue 6

Management of Septic Bursitis

• If septic bursitis is suspected (fever >37.8°C, skin lesions, purulent aspirate), antibiotic therapy should be initiated 4
• Staphylococcus aureus is the most common infecting organism in septic prepatellar bursitis 5
• Intravenous antibiotics with splinting and aspiration are usually successful, though some cases may require surgical drainage 7

Surgical Management

• Surgical intervention (bursectomy) should be reserved for cases that fail 3-6 months of conservative management 1, 8
• Endoscopic bursectomy under local anesthesia has shown good results with minimal scarring and quick recovery 8
• Novel treatments such as sclerotherapy have shown promise in recalcitrant cases 9

Prognosis and Prevention

• Most patients with prepatellar bursitis recover fully with appropriate conservative treatment 1
• Recurrence is common, particularly in those who kneel at work (such as plumbers, carpet layers, and wrestlers) 7, 5
• Protective knee pads are recommended for prevention in those with occupational risk factors 5

Important Considerations

• Differentiation between septic and non-septic bursitis is crucial for appropriate management 4
• Aspiration with Gram stain and culture should be considered in all cases of prepatellar bursitis, as 50% of septic cases may not show clinical evidence of infection 5
• Chronic or recurrent bursitis may lead to pathologic changes in the bursal wall that impair its defense mechanisms 5